Form Vs-166 - Application For A New Birth Certificate Based On Parentage Form
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1
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3APPLICATION FOR A NEW BIRTH CERTIFICATE BASED ON PARENTAGE
BUDGET ZZ 708-153
This form is used to ADD, REMOVE, or REPLACE information regarding the parents listed on the original birth
certificate according to an establishment of PARENTAGE or a COURT ORDER.
Child’s original birth information:
Type or Print in Blue/Black Ink
Texas
__________________________________________________
Date of Birth:____________/__________/____________ Place of Birth:____________________________________________,
Full name of child as registered at birth
month
day
year
city
Father’s name
Mother’s full maiden name
:________________________________________________________________
:________________________________________________________________________________
We/I hereby request a new birth certificate be filed as evidenced by:
ONE
PLEASE CHECK
OF THE FOLLOWING:
Attached certified copy of court decree (must send all pages of the court order) OR
A properly completed Acknowledgment of Paternity (form VS-159.1) (Date form was faxed to Vital Statistics Unit (VSU) or signed before a
certified entity: _________________) OR
Attached certified copy of the parents’ marriage license
A properly completed Rescission of Acknowledgment of Paternity (form VS-158) (Date Mailed to VSU _______________ )
INFORMATION TO BE PLACED ON NEW BIRTH CERTIFICATE:
:____________________________/_____________________/________________________________
FULL NEW NAME OF CHILD (may require a court order)
First
Middle
Last
Title To Appear On Birth Record:
Mother
Father
Parent; If Mother, Full Maiden Name
___________________/______________/_____________________
First
Middle
Last
Parent’s Name:
_____________________/______________/_____________________ Date of Birth:______/_____/________ Place of Birth:__________________________________
First
Middle
Last
month day
year
State or Foreign Country
Title To Appear On Birth Record:
Mother
Father
Parent; If Mother, Full Maiden Name
___________________/______________/_____________________
First
Middle
Last
Parent’s Name:
___________________/______________/_________________________ Date of Birth:______/_____/_______Place of Birth:__________________________________
First
Middle
Last
month day
year
State or Foreign Country
WARNING: The Penalty for knowingly making a false statement in this form can be 2-10 years in prison and a fine of up to $10,000. (Texas Health
and Safety Code, Chapter 195).
___________________________________________________________________________
_____________________________________________________________________________
Signature of PARENT or Legal Guardian swearing to this affidavit
Signature of PARENT or Legal Guardian swearing to this affidavit
______________________________________________________________________
________________________________________________________________________
Address
city
state
zip code
Address
city
state
zip code
(_____)_____________________________
(______)__________________________________
Daytime telephone number
Daytime telephone number
Sworn to and subscribed before me, this _________day of ______________________,
Sworn to and subscribed before me, this __________day of ______________________,
20_________.
20___________.
_____________________________________________________________________
_______________________________________________________________________
Signature of Notary Public, County Clerk, or other person
Signature of Notary Public, County Clerk, or other person
authorized to administer oaths
authorized to administer oaths
______________________________________________________________________________________
_________________________________________________________________________________________
Printed name and title
Printed name and title
SEE REVERSE SIDE FOR INSTRUCTIONS
The fee for filing a new birth certificate is $25.00 An additional fee of $22.00 must be included for a certified copy of the new birth certificate.
Mail this completed and NOTARIZED application with either the attached evidence (certified copy of court order/ marriage license), or filed an
Acknowledgment of Paternity, and the required fee to:
TEXAS VITAL STATISTICS
PO BOX 12040
AUSTIN TX 78711-2040
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